Breast health

What is lumpectomy?

Called breast conserving therapy because it strives to preserve the breast's appearance by removing only a portion of it, lumpectomy is the most common form of breast cancer surgery today. Sometimes called wide incision biopsy, partial mastectomy, wedge resection, or re-excision, lumpectomy refers to the surgical removal of a malignant tumor in the breast, along with a small margin of the surrounding normal breast tissue. Where lumpectomy involves removal of up to one fourth of the breast, it is called a quadrantectomy. In some cases, a separate incision may be needed to include a sampling or removal of the axillary lymph nodes. Done to determine whether the cancer has begun to spread out of the breast tissue, this additional incision may be a sentinel node biopsy, an axillary lymph node sampling, or an axillary node dissection. (See Breast Biopsy for more information on the various types of breast biopsy.)¹

Who is a candidate for lumpectomy?

To determine whether a patient is a candidate for lumpectomy, her physician will stage her cancer to determine the extent of the disease and the appropriate course of treatment. Lumpectomy is usually a suitable treatment option for women diagnosed with ductal carcinoma in situ, Stage I, Stage II or Stage III breast cancer. (For more information, see Staging Breast Cancer at Imaginis.com for more information.)

Lumpectomy is usually combined with at least six weeks of radiation therapy in order to ensure that any cancer cells in the remaining breast tissues are destroyed. While still under investigation, recent studies have suggested that shorter radiation times may be equally effective in the prevention of local tumor recurrence. Other therapies given in addition to lumpectomy include agents such as chemotherapy, tamoxifen (also known as Nolvadex), and hormonal or drug therapy: all of these adjuvant therapies are designed to control the systemic spread of breast cancer.²

Who is not a candidate for lumpectomy?

According to the American Cancer Society, the following may not be suitable candidates for lumpectomy:

• women who have previously undergone radiation in the chest/breast area
• women with multicentric disease (two or more areas of cancer in the same breast)
• women with extensive cancer in the breast
• women whose previous lumpectomy did not completely remove the cancer
• women with connective tissues such as sclerodoma, lupus, or vasculitis (since such diseases make tissue sensitive to radiation and its side effects)
• women who are pregnant or may become pregnant at the time of radiation therapy (because of the risk radiation poses to the fetus)
• women whose cancers are more than 2 inches (5 cm) in diameter
• women with larger cancers within relatively small breasts (removal of such tumors through lumpectomy can be very disfiguring)

While some women are not suitable candidates for lumpectomy, readers should note that the type of breast cancer surgery a patient receives sometimes depends on her surgeon's own preference. If you have been diagnosed with breast cancer, be sure to carefully discuss your treatment options with your surgeon and other members of your oncology team. Although lumpectomy is becoming an increasingly suitable option for many women with early stage breast cancer, Women's Web recommends that you seek a second opinion before undergoing breast surgery.

How is lumpectomy performed?

Depending on the extent of surgery needed to remove the tumor, lumpectomy may be performed under local anesthetic, under sedation, or under general anesthesia. On average, the procedure can last between 20 and 90 minutes, and the surgical incision is usually curved, following the natural curve of the breast and allowing for better healing.³

If your surgery involves the removal of lymph nodes, you will more than likely be under general anesthesia. You will be instructed not to eat or drink anything for at least 8 hours before your operation. When you arrive at the hospital, you will be asked to sign an informed consent form, and you doctor will answer any last-minute questions you might have and will also explain any risks associated with your operation. You will then receive anesthesia and any necessary medications. A nurse will begin an intravenous line to administer fluids and medication you may need during your surgery. You may also receive a sedative. The anesthesiologist will then perform a brief medical examination, take your medical history, and ask about any medications you are currently taking, any allergies you have, and any adverse reactions to anesthesia. The information you provide will help assess any problems or conditions that may affect the choice of anesthesia, and it will also help the surgical team determine whether any special precautions need to be taken.

Through a small incision made over or near the breast tumor and using an electrocautery knife (a type of scalpel that uses heat to minimize bleeding), the surgeon excises the lump or tumor along with a half-inch (1 cm) margin of normal surrounding breast tissue. Removal of a small margin of breast tissue surrounding the tissue is as important as removal of the tumor itself. This is because this margin of surrounding tissue is examined by a pathologist once the lumpectomy is performed. By checking to see whether the outermost edges of the breast tissue sample are free of cancer (or "clear"), the pathologist can determine whether the surgeon removed the entire cancerous tumor.

A preliminary check of tissue margins may be performed while the patient is still in the operating suite, thereby allowing the surgeon to obtain clear margins during the same operation. A preliminary reading, however, should never be used to make a final decision. Final results, available over the course of a few days, may reveal residual cancer cells in what's known as a positive margin. If the margins of the removed breast tissue do reveal cancer cells, re-excision is necessary to attempt to remove the remaining cancer (or "clear the margins"). Re-excision lumpectomy involves going back into the area operated on during your previous lumpectomy: your surgeon will remove the tissue that used to surround your tumor in an effort to ensure all cancer is gone. Of course, if removal of cancer from the margins is not possible through re-excision, a mastectomy is usually presented as an alternative.⁴

After surgery

After the operation, a clear fluid known as seroma usually fills the surgical cavity and helps naturally restore the breast's shape. Over time, the body absorbs the seroma and replaces it with scar tissue. All part of the natural healing process, the formation of scar tissue takes place over the course of several months. As such, the final results of the surgery may not be evident for some time. Of course, the final result will vary from one patient to another, depending on the location of the tumor, its size, and the type and size of the surgical incision.⁵

Lumpectomy, if it does not involve the removal of lymph nodes, is typically performed under local anesthetic on an outpatient basis. Patients can expect to go home the same day. Be sure there is someone with you at the hospital who can take you home and ensure you are comfortable once you are there.

Because lumpectomy with lymph node dissection is an invasive procedure, patients are usually discharged from hospital one or two days following surgery and can resume normal activities within two weeks. Infection and bleeding are not common with lumpectomy. Usually subsiding in two to three days following surgery, a patient can expect to feel overall soreness where the tumor was removed. The amount of pain a patient experiences is related to the amount and location of tissue removed during surgery, whether axillary lymph node surgery was performed (see Breast Biopsy for more information), and the patient's pain threshold. Although pain can be managed with a pain reliever taken as directed, pain that does not subside or pain that increases over time should be discussed with a physician.⁶

In rare instances, some patients experience recurring seromas (tumor-like collections of serum in the surrounding tissues) following surgery. Seromas collect in the cavity left behind after surgery and are typically drained in a doctor's office. However, if seromas recur, surgeons may use compression or the injection of ethanol, autologous fibrin clot, or fibrin sealant to fill and harden the space in the breast.⁷

Once you are home, be sure to follow your surgeon's instructions for home care. You may be given a soft plastic drain to help draw off fluid from around the incision. Your surgeon will likely instruct you to use the drain once every 8 hours and to measure and record the amount of fluid drained.⁸

Patients should seek medical attention if they experience fever, cough, chest pain, shortness of breath, excessive bleeding, or increased pain, warmth, drainage, swelling, or redness at the incision site. These can indicate infections or complications.

A dressing will cover your incision and stitches. You should be able to shower and bathe as normal, provided you keep the dressing dry. Your doctor may ask you to remove the dressing in a day or two, or he or she may remove it when you go in for a follow-up appointment, at which time he or she will remove your stitches.

Are there any risks or side effects?

Depending on the size of the tumor removed, patients may experience a loss of sensation in the breast. Some or most of this sensation will return in time.

Following lumpectomy, a patient's breasts may not match in size and shape. This is because removal of breast tissue during surgery usually makes the affected breast appear smaller. Conversely, swelling in response to surgery may make the affected breast appear larger. Patients may also notice dimpling and scarring.

Though rare with lumpectomy, wound infection and bleeding may occur. Patients should consult a physician if they experience either of these. Infections can usually be treated with antibiotics and a doctor will also be able to treat any hematoma (accumulation of blood in the wound) that may occur as a result of surgery.

If your surgery will also involve removal of lymph nodes, you may find that the area under your arm is swollen. This is because the surgery has impacted lymph's ability to drain from the arm. The swelling is known as lymphedema and may be accompanied by numbness, discomfort, and sometimes infection. Lymphedema can also occur as the result of radiation therapy. Your doctor may recommend a massage-like treatment designed to stimulate the lymphatic vessels. You can also limit problems by:⁹

• slowly returning to normal use of the arm on the surgery side by using it to perform light tasks such as dusting, writing, and weeding
• protecting the hand and arm from infection by washing regularly and by using gloves when gardening, handling household trash, and housecleaning
• avoiding tight sleeves, elastic cuffs, bracelets, wristwatches, or rings that may constrict movement of lymph throughout the arm and hand
• doing exercises such as squeezing a rubber ball for a few minutes each day; these types of exercises help stop swelling and improve circulation

Is lumpectomy effective?

Studies have revealed that women with small breast tumors who undergo lumpectomy followed by a full course of radiation have an equal chance of surviving breast cancer as those who undergo mastectomy, a surgical procedure which involves complete removal of the breast. Furthermore, according to a recent study by Yale researchers, women with very early-stage breast cancers who undergo lumpectomy followed by radiation are no more likely to develop a second cancer than women who undergo mastectomy. This is assuming, of course, that candidates are selected appropriately and that the edges of the surgical sample are free of cancer cells. Because it allows women to retain most of their breast after surgery and because there is no statistically significant difference in overall survival rates between women who undergo lumpectomy (and radiation) and those who undergo mastectomy, lumpectomy may be a more attractive surgical alternative for women with small, localized breast cancers.¹⁰

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3. Lumpectomy: What to Expect. breastcancer.org (2004)
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   Re-excision. breastcancer.org (2004)
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8. Lumpectomy. Memorial Hospital of Rhode Island (2002)
9. Ask-the-Expert Conference: Arm Lymphedema-Prevention and Management. breastcancer.org (2004)
   Lumpectomy. Memorial Hospital of Rhode Island (2002)
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